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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:07:42 AM


Document Has Been Signed on 10/03/2022 10:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PANGO'S CARE HOMEFACILITY NUMBER:
342701101
ADMINISTRATOR:PANG LILY VUEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(916) 508-6319
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 0DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pang VueTIME COMPLETED:
11:00 AM
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On 10/3/22 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection to ensure all previous corrections had been made and to ensure the facility is ready to accept residents again.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. Back and front yards have been cleared of all debris and patio furniture and shade is available to future residents.

LPA measured the water temperature, temperature measured at 106 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete.

LPA received fire clearance from SFD which approved a fire clearance for 4 non-ambulatory residents in bedrooms 3, 4 and 5 only. Rooms 1 and 2 are dedicated for ambulatory residents only.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. The facility is cleared to accept residents again. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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